Basic Information
Provider Information | |||||||||
NPI: | 1437369022 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIOR RADIOLOGY SERVICES PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 136 FIORANELLI DR | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | MS | ||||||||
PostalCode: | 387017313 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6623349829 | ||||||||
FaxNumber: | 6623343529 | ||||||||
Practice Location | |||||||||
Address1: | 1400 E UNION ST | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | MS | ||||||||
PostalCode: | 387033246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6623349829 | ||||||||
FaxNumber: | 6623343529 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2007 | ||||||||
LastUpdateDate: | 12/08/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRIOR | ||||||||
AuthorizedOfficialFirstName: | DONALD | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6623349829 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 14756 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 01100733 | 05 | MS |   | MEDICAID | 184441304H | 01 | MS | BLUE CROSS MS | OTHER | DA8940 | 01 | MS | RAILROAD MEDICARE | OTHER |